Provider Demographics
NPI:1023137619
Name:MIRANDA, KENNETH (LPT)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:MIRANDA
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 WOODSIDE AVE
Mailing Address - Street 2:BLDG W-3
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94127-1221
Mailing Address - Country:US
Mailing Address - Phone:415-753-4443
Mailing Address - Fax:
Practice Address - Street 1:375 WOODSIDE AVE
Practice Address - Street 2:BLDG W-3
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94127-1221
Practice Address - Country:US
Practice Address - Phone:415-753-4443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12479167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
486OtherCBHS INTERNAL USE ONLY-COMMERCIAL NUMBER
486OtherSFGH INTERNAL USE ONLY